Early Neurological Change After Ischemic Stroke Is Associated With 90-Day Outcome

Abstract

Background and purpose: Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSSbaseline - NIHSS24hours = ΔNIHSS6-24h), to examine its relevance to AIS mechanisms and long-term outcomes.

Methods: Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS6-24h. In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS6-24h was examined. Finally, the association of ΔNIHSS6-24h with 90-day favorable outcomes (modified Rankin Scale score 0-2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA).

Results: For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4-16), and median ΔNIHSS6-24h was 2 (interquartile range, 0-5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS6-24h (R2=0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R2=0.27), but much of the variance remained unexplained. ΔNIHSS6-24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS3-24h was similarly associated with 90-day outcomes.

Conclusions: The dynamic phenotype, ΔNIHSS6-24h, captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS6-24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.

Keywords: genome-wide association study; phenotype; population; stroke, ischemic.

Conflict of interest statement

Potential Conflicts of Interest

No other potential conflicts of interest were reported by co-authors.

Figures

Figure 1:

Frequency distribution histograms of baseline, 24-hour and ΔNIHSS6–24h in the GENISIS cohort. A) Distribution of baseline (collected within 6 hours of last known normal) NIH stroke scale scores (NIHSS). B) Distribution of the 24 hour (+/− 4 hours) NIHSS scores. C) Distribution of ΔNIHSS6–24h (calculated as baseline NIHSS – 24 hour NIHSS).

Figure 2.

Frequency distribution of ΔNIHSS6–24h by TOAST etiology in the GENISIS cohort. TOAST = Trial of Org 10172 (stroke etiology designations); LAA = large artery atherosclerosis; CE = cardioembolic; SVD = small vessel disease; UND = undetermined.